Electro-convulsive therapy

Question 1

Sakel

Answer 1

Insulin-induced hypoglicemia

Question 2

Cerletti and Bini

Answer 2

Electricity-induced seizures

Question 3

Modified ECT

Answer 3

1950s

Question 4

Monitored ECT

Answer 4

1980s

Question 5

Bried-pulse waveform

Answer 5

1980s

Question 6

Main indications (when to use ECT)

Answer 6

• major depression (unipolar or bipolar)
  > good prognosis: anorexia, psychomotor retardation, catatonia, mood-congruent
  > poor prognosis: hysterical phenomena, somatization, chronic pain
• mania
• catatonic schizphrenia

Question 7

Use in major dperession

Answer 7

First line:

• urgent need to treat
• previous good response
• psychotic or catatonic features

Question 8

Mechanisms of action

Answer 8

• unclear, but clearly due to the seizure, NOT due to amnesia or “punishment”.
• seizure increase catecholamine synthesis and turnover, leading to down regulation of beta-adrenergic receptors
• it can change patterns of blood flow through the brain and change the metabolism of areas of the brain
• increased dopamine may play some role

Question 9

Preparations for ECT

Answer 9

• Discontinue all psychotropic drugs, especially benzodiazepines, possibly cholestrerase inhibitors
• informed consent
• second opinion
• anaesthesia work-up
• neuologic exam, neuroimaging study

Question 10

Usual course of ECT

Answer 10

• 6-15 treatments, given three times per week (can reduce to twice weekly to decrease confusion)
• aim for 25 to 60 sec seizures by EEG
• treat until patient plateaus or is back to baseline, then two or three more treatments

Question 11

Electrode placement

Answer 11

in bilateral ECT, the electrical current is passed across the whole brain

in unilateral ECT, the current is just passed across one side. both of them cause a seizure in the whole of the brain

Less memory deficit with unilateral non-dominant placement, but;

• many patient don’t respond to unilateral treatment
• may require more treatments
• seizures may not generalize
• stimulus need to be further supra threshold than for BL treatment.

Question 12

Side effects

Answer 12

• reversible short-term memory deficit
• confusion
• headache, muscle soreness
• broken bones and teeth (extremely rare since advent of modified ECT)
• anaesthesia risk
• cardiac risk

OVERALL risk: death/serious injury occurs in about 1 in 80.000 treatment